Pearl of the Day: Easy IJ

Easy Internal Jugular (IJ)

- placement of single-lumen catheter into IJ using ultrasound guidance

- in a prospective study by Moayedi et al. 2016, 83 attempts recorded in 74 patients with initial success rate 88% and mean procedure time 4.4 min; complications included loss of patency in 14% (95% CI 7 - 24%), and 0/83 with pneumothorax, line infection, arterial puncture

Indications

- patients who do not require triple lumen catheter but with difficulty in obtaining peripheral access

Materials

- ultrasound with linear probe

- chlorhexidine

- 18-gauge catheter at least 2 inches long

- sterile probe cover

- sterile lubricant

- sterile gloves

Procedure

- similar to ultrasound-guided peripheral IV placement

- increased success may be achieved with Trendelenburg position and Valsalva maneuver with head turned toward opposite side of target vein

- does not require full sterile drape or gown

Post-procedure Recommendations

- may check CXR to r/o pneumothorax

- intended for 24 hour use, but may be left in longer, up to 7 days in some studies

Resources

Butterfield M et al. Using Ultrasound-Guided Peripheral Catheterization of the Internal Jugular Vein in Patients with Difficult Peripheral Access. Am J Ther 2015. PMID 26469683

Moayedi S et al. Safety and efficacy of the “easy internal jugular (IJ)”: an approach to difficult intravenous access. J Emerg Med. 2016; 51(6): 636-642. PMID 27658558

Pearl of the Day: Blunt Cardiac Trauma

Blunt Cardiac Injury (BCI) Pathophysiology - most often involves the right heart due to its anterior location

Management - if normal EKG but concern for BCI, monitor for 4 - 6 hours with repeat examinations, EKGs, cardiac monitoring - if abnormal EKG but no hemodynamic instability, admit to monitored setting EKG - NPV with normal EKG = 80 - 90% - more sensitive for LV than right-sided injury - nondiagnostic findings (e.g., nonspecific ST-T wave changes) do not aid in diagnosis of BCI

Cardiac Biomarkers - CK-MB has no value in traumatic injury - troponins may be elevated in all myocardial trauma - troponins can be used with EKG to risk-stratify patients - clinically significant BCI can occur without elevation of troponins, but usually have abnormal EKG

Echocardiography - POC ultrasound has been shown to have 100% sensitivity, 99% specificity for pericardial effusions - TTE or TEE has not been helpful in identifying patients at risk for developing BCI complications - should be ordered for patients with elevated cardiac markers, dysrhythmias, or myocardial dysfunction

Types of Injuries

Commotio Cordis - sudden arrest from blunt trauma to chest wall - primary electrical event causing ventricular fibrillation - no evidence of anatomic injury

Cardiac Dysfunction - decreased contractility - blunt injury to lung -> increased pulmonary vascular resistance -> reduction in preload of LV -> hypotension - RV with decreased cardiac output - management: monitor for dysrhythmias

Pericardial Injury - pericardial tears usually occur at the left of pericardium parallel to phrenic nerve and may be site of herniation - management: usually surgical unless tear is too large

Injury to Cardiac Valves, Papillary Muscles, Chordae Tendineae, and Septum - involvement of aortic valve > mitral and tricuspid valves - aortic valve injury -> widened pulse pressure, acute valvular insufficiency, cardiac failure - muscular septum can rupture several days after trauma - management: surgery

Injury to Coronary Vessels/Myocardial Infarction - rare - most commonly involves LAD - management: PCI with stenting - fibrinolytics are contraindicated, cautious use of anticoagulation

Cardiac Rupture - most die at the scene - right heart is more susceptible due to anterior location, thin-walled atrium - "splashing mill wheel"/"bruit de Moulin" murmur - EKG shows conduction defects, axis deviation - management: immediate thoracotomy

Resources Tintinalli's Emergency Medicine, 8th edition

Pearl of the Day: Otitis Externa

Otitis Externa (OE) Etiology - Pseudomonas aeruginosa, Staphylococcus aureus - occurs with conditions that alter the normal external ear canal flora (e.g., exposure to moisture, direct trauma to ear)

Signs/Symptoms - early stages:  ear fullness, itching - erythematous ear canal, tender pinna and tragus - pain exacerbated by manipulation of auricle or range of motion of TMJ - usually normal tympanic membrane

Diagnostic Criteria - rapid onset within 48 hours in the past 3 weeks of at least one primary symptom (otalgia, itching, fullness) AND - one primary sign (tenderness of tragus/pinna or diffuse ear canal edema/erythema)

Treatment - attempt to remove debris to increase efficacy of topical medication - steroid-antibiotic combination drops (e.g., ciprofloxacin with dexamethasone) - for mild OE (without TM perforation), may use acidifying therapy (e.g., boric acid, acetic acid) - cotton wick can be placed to get drops deeper toward tympanic membrane

Cotton Wick - can be made from narrow gauze (0.25 inch packing) or from hard sponge material that expands (e.g., Merocel) - medication is placed onto external end of ear wick, which is then pulled into the ear canal - antibiotic drops should be placed 2 - 4 times daily - may fall out as edema decreases - should be removed after 2 - 3 days

Surgical Debridement and Drainage - reserved for necrotizing OE, complications of OE, significant amount of discharge, fungal infections - failure of prolonged antibiotic therapy

Systemic Antibiotics - only for extension of disease outside of ear canal and/or host is immunocompromised - if started, should consider cultures of ear canal

Complications - external canal stenosis - requires debridement - abscess formation (usually with S. aureus infections) - requires I&D by ENT - malignant OE/necrotizing OE from P. aeruginosa caused by local invasion into skull and underlying structures

Discharge Instructions - keep ear canal dry - place earplug or cotton ball coated with petroleum jelly in ear canal when bathing/showering - may resume aquatic activities once infection is treated (usually 4 - 5 days)

Resources https://emedicine.medscape.com/article/994550 Peer IX Tintinalli's Emergency Medicine, 8th Edition